Rob “John” Garner, MA, LMHC, LPC

Website: www.CounselorCobberJohn.com
Email: john@counselorcobblerjohn.com

Supervision Disclosure Statement and Service Agreement

for Counselor Cobbler John’s Clinical Supervision Online

SERVICES

Supervisors who are licensed by the Washington Department of Health and the Oregon Board of Licensed Professional Counselors and Therapist can provide supervision, which is defined as “the regularly occurring examination of the counselor’s work to promote personal and professional development, foster acquisition and refinement of skills, and encourage responsible provision of services and programs.” This service will provide a confidential professional relationship in which my roles as consultant, teacher/trainer, counselor and evaluator will intermingle within the supervisory process. Should you have additional questions after reading this statement, please do not hesitate to ask.

CONFIDENTIALITY

The confidentiality laws of the State of Washington and Oregon protect any information regarding your client’s identity, written or discussed in this office.  Except in rare situations, information will not be released to anyone without your client’s written permission. The exceptions to confidentiality of information obtained in the course of services include: reporting suspected child abuse; reporting imminent danger to self, others or property; reporting to relevant agencies; licensee consultation or supervision and defense of claims brought by client against licensees and their supervisors.  In the event that I might need to consult with an outside expert, I would first request you and your client’s written consent.

PROFESSIONAL QUALIFICATIONS

Master of Arts in Counseling Psychology, Lewis & Clark College, 1988.

Licensed Mental Health Counselor (LMHC), State of Washington, LH# 00003942. Verify here

Licensed Professional Counselor (LPC), State of Oregon, C# 0699. Verify here

Supervision training, 30 clock hours of coursework, Portland State University, 1994.

Professional Affiliations: Washington Department of Health and Oregon Board of Licensed Professional Counselors & Therapists,

CLINICAL EXPERIENCE

  • Five years providing clinical treatment for severely disturbed children within a residential setting.
  • Eighteen years clinically treating severely disturbed children, adolescents, and families within an outpatient community mental health setting.
  • One year clinically treating chronically mentally ill adults within a group home setting.
  • Eight years providing clinical treatment to adults and children within a part-time private and group practice settings.
  • Eighteen months providing Neurofeedback Treatment.

SPECIALTIES

Child & Adolescent Treatment

Sexual abuse & Trauma recovery

Family Treatment

Individual Adult Therapy

Cognitive Behavior Therapy

Couples Therapy

Integrated Neurofeedback Counseling Treatment

SUPERVISORY EXPERIENCE

  • Executive Director for two years directing and supervising a volunteer peer counseling program within a rural setting.
  • Associate Executive Director, Director for Child & Family Services, Program Manager for nine years clinically supervising mental health counselors providing Building Based Day Treatment in schools and Community Outreach Support Programs.
  • Program Director, one-year clinically supervising residential treatment workers treating chronically mentally ill adults within a group home setting.
  • Team Leader, nine years clinically supervising mental health counselors within a rural setting.

CLINICAL ORIENTATION

Interpersonal Object-Relations

Family Systems

Cognitive Behavior Therapy

Integrated Neurofeedback Counseling Treatment

SUPERVISORY ORIENTATION

Blending of Interpersonal Object-Relations and Systems Theories.
Four fold focus:
  1. Supervisees understanding of own countertransference.
  2. Client impact upon Supervisee.
  3. Management of stress reactions.
  4. Differentiation between Client and Supervisee issues within the counseling situation.

LEGAL & ETHICAL OBLIGATIONS FOR SUPERVISORS

According to the Washington and Oregon State Law, “Supervisors who are licensed by the Board will be held accountable for the effects of any Supervisee actions of which the supervisor is, or ought to be aware.”  If in my clinical judgement, I find the counseling services that you are providing to be unethical or unprofessional, I am bound by law and my code of ethics as a supervisor to issue a complaint to the Washington Health Department and/or the Oregon Board and the professional ethics board(s) that you subscribe to.

REQUIREMENT

You are responsible to make available upon request copies of the following:

  1. Current malpractice/liability insurance receipt.
  2. Ethical standards you are bound to abide by.
  3. Current client disclosure statement.
  4. Verification of relevant diplomas, licenses and certifications.
  5. Evidence of Professional counseling affiliations.
  6. Signed copy of current state laws related to counseling indicated by your signature that you have read and are familiar with them thoroughly.
  7. Client’s written consent to consult with me.
  8. A thorough written assessment and treatment plan for each client discussed in supervision.
  9. Written progress notes, which directly pertain to problem areas and goals, within the individual treatment plan for each client discussed in supervision.
  10. Supervision requirements for certification/licensure.
  11. A written statement of your professional goals and interests for supervision.

I am responsible to make available upon request copies of each of the following:

  1. Current malpractice/liability insurance receipt.
  2. Ethical standards that I am bound to abide by.
  3. Current client disclosure statement.
  4. Verification of relevant diplomas, licenses and certification.
  5. Evidence of professional counseling affiliations.
  6. Evidence of clinical & supervisory experience.

FEES, PAYMENT & APPOINTMENTS

Supervision services are billed at the rate of $90.00 per hour and are payable at the time of the appointment.  Telephone and emergency consultations are billed at the above hourly rate.  Appointments are scheduled in advance and are 60 minutes in length. If you are late, the appointment will not be extended to redeem this time.  Scheduled appointments may be cancelled without charge of the cancellation occurs more than 24 hours in advance. If you have to cancel your appointment with less than 24 hours notice you will be charged for your appointment and payment is due before another appointment is scheduled. In the event of illness, one hour’s notice is required.

EMERGENCY CONSULTATIONS

If an emergency arises and you need to consult with me, call the above phone numbers and leaves a message.  I will try to return your call as soon as possible.  If I am unavailable and you need immediate support contact your local County Crisis Center and/or 911.

RIGHTS AND RESPONSIBILITIES

Please read Guidelines for Post-Degree Supervision and the attached papers below; Washington Mental Health Counselors, “What to Expect Brochure” and “Oregon Board Bill of Client Rights”. If you find the supervision provided to be unethical or unprofessional, you have the right to issue a complaint to the Oregon Board of Licensed Professional Counselors & Therapists and the Health Department of the State of Washington.  I subscribe to these organization’s Code of Standards & Ethics.

As a licensee and/or counseling professional you are expected to abide by the Washington Board of Health and/or the Oregon Board’s Code of Ethics and/or your own professional affiliation’s Code of Ethics and are subject to disciplinary action by these Boards.

ATTESTATION

I attest that I am an adult over 18 years of age and agree to all information outlined in the Supervision Disclosure Statement and Service Agreement for Counselor Cobbler John’s Clinical Supervision Online form above. On scheduling and making prepayment through the Schedule & Pay button link for my first video counseling & life coaching session, I clicked on the Read & Agree button link following confirmation of informed consent and secured a copy of the Supervision Disclosure Statement and Service Agreement for Counselor Cobbler John’s Clinical Supervision Online for myself.

I sent Mr. Garner a confirmation email to this email address (click the following address hyperlink): john@counselorcobblerjohn.com and on the Subject Line wrote the following: Supervision Disclosure Statement & Service Agreement. In the Body of the e-mail, I typed the following (copy & paste the following): I have read, understand, and agree to the statement on Supervision Disclosure Statement and Service Agreement for Counselor Cobbler John’s  Clinical Supervision Online regarding receiving clinical supervision with Rob “John” Garner, LMHC, LPC.” At the end of this statement, I typed my Name that he will know me by as my electronic signature confirming my agreement to this  Supervision Disclosure Statement and Service Agreement. 

I understand that upon Mr. Garner’s receipt of this email confirmation, he will send to me a reply to this email acknowledging receipt of this email confirmation and include his electronic signature in a return email for my records. I understand that this second step is completed only once (unless this disclosure statement/agreement is revised) and after completed I may access Mr. Garner’s services at my and his discretion through the Let’s Consult link that will take me to his HIPAA compliant cyber-waiting room, which is a browser-based software program called Doxy.me.

 

Washington Mental Health Counselors, “What to Expect Brochure”

Click this PDF link to view brochure: here

Oregon Licensed Counselors and Therapists, “What to Expect Document”

Click this PDF link to view document: here

 

6/16: RJG

Counselor Cobbler John 2019